An Individual Participant Data Meta-analysis of Maternal Going-to-Sleep Position, Interactions with Fetal Vulnerability, and the Risk of Late Stillbirth

Cronin, Robin; Li, Minglan; Thompson, John M. D.; Gordon, Adrienne; Raynes‐Greenow, Camille; Heazell, Alexander; Stacey, Tomasina; Culling, Vicki; Bowring, Victoria; Anderson, Ngaire; O’Brien, Louise M.; Mitchell, Edwin A.; Askie, Lisa; McCowan, Lesley

doi:10.1016/j.eclinm.2019.03.014

Cited by 51 publications

(107 citation statements)

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“…In keeping with the findings of others we found that women in Australia who were born in South Asia, Africa and Oceania are at higher risk of having a stillbirth after 24 weeks gestation compared to locally born women, even after adjustment for confounders.…”

Section: Discussionsupporting

confidence: 92%

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004–2015

Berman

Ibiebele

Patterson

et al. 2019

Aust NZ J Obst Gynaeco

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Background: Research suggests that in Australia, maternal region of birth is a risk factor for stillbirth. Aims:We aimed to examine the relationship between stillbirth and maternal region of birth in New South Wales (NSW), Australia from 2004 to 2015.Methods: Adjusted logistic regression was used to determine odds of stillbirth by maternal region of birth, compared with Australian or New Zealand-born (AUS/ NZ-born) women. Intervention rates (induction or pre-labour caesarean) by maternal region of birth, over time, were also examined. Interaction terms were used to assess change in relative odds of stillbirth, over two time periods (2004-2011 and 2012-2015).Results: There were 944 457 singleton births ≥24 weeks gestation that met the study inclusion criteria and 3221 of these were stillbirths, giving a stillbirth rate of 3.4 per 1000 births. After adjustment for confounders, South Asian (adjusted odds ratio (aOR) 1.42, 95% CI 1.24-1.62), Oceanian (aOR 1.45, 95% CI 1.17-1.80) andAfrican (aOR 1.46, 96% CI 1.19-1.80) born women had significantly higher odds of stillbirth that AUS/NZ-born women. Intervention rates increased from the earlier to the later time period by 13.1% across the study population, but the increase was larger in African and South Asian-born women (18.1% and 19.6% respectively) than AUS/NZ-born women (11.2%). There was a significant interaction between ethnicity and time period for South Asian-born women in the all-births model, with their stillbirth rates becoming closer to AUS/NZ-born women in the later period.Conclusion: South Asian, African and Oceanian maternal region of birth are independent risk factors for stillbirth in NSW. K E Y W O R D Sbirth intervention, ethnicity, gestational age, maternal region of birth, stillbirth

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Section: Discussionsupporting

confidence: 92%

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004–2015

Berman

Ibiebele

Patterson

et al. 2019

Aust NZ J Obst Gynaeco

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“…Participants comprised 851 late stillbirth cases and 2257 controls with ongoing pregnancies from five eligible case-control studies (Fig 1): the Auckland Stillbirth Study [26], the New Zealand Multicentre Stillbirth Study [31], the Sydney Stillbirth Study [27], the UK Midlands and North of England Stillbirth Study [30], and the International Study of Trends and Associated Risks for Stillbirth Study [32], comprising women of many ethnicities [24]. Differences in maternal and pregnancy characteristics, infant size, and going-to-sleep position between cases and controls have been previously reported (S1 Table) [24]. 'Any' snoring (cases n = 473, 56.0%; controls, n = 1182, 54.1%), sleep quality (fairly bad to very bad, cases n = 248, 33.5%; controls, n = 703, 35.3%), daytime sleepiness (positive ESS score �10, cases n = 128, 17.5%; controls n = 312, 15.8%), and frequency of getting up to use the toilet (�1 per night, cases n = 667, 90.0%; controls, n = 1820, 91.5%) last month were not associated with late stillbirth in the univariable analysis.…”

Section: Resultsmentioning

confidence: 99%

“…The study population comprised cases with late stillbirth and controls with ongoing pregnancies from the CRIBSS data. This IPD meta-analysis was registered with the PROSPERO register of systematic reviews (CRD42017047703) and followed the IPD meta-analysis protocol [38], search strategy [24], risk of bias for non-randomised studies (ROBINS-E) tool [39], and published results [24]. Five international case-control studies [26,27,[30][31][32] that collected maternal going-to-sleep position and late stillbirth data were included in this pooled IPD meta-analysis.…”

Section: Methodsmentioning

confidence: 99%

“…These may be factors contributing to our finding of a significant interaction between habitual snoring during the last month and supine going-to-sleep position, with a lower odds of late stillbirth than expected in women who reported both during the last month. While this may be a chance finding due to low prevalence, with 17 (12 controls and 5 cases) of 92 women reporting habitual snoring and a supine going-to-sleep position, this could also be explained by the women being woken by a sleep companion or experiencing a self-arousal due to snoring, and moving from the supine to a lateral position, which is known to reduce third trimester snoring in obese women [23] and late stillbirth risk [24].…”

Section: Plos Onementioning

confidence: 99%

“…SDB is a risk factor for adverse pregnancy outcomes, including gestational hypertension and pre-eclampsia [4,9,10], hyperglycaemia [11][12][13], impaired fetal growth [14][15][16][17][18][19], and early-term and/or preterm birth [9,14,[20][21][22]. SDB is exacerbated by obesity, advanced gestation, and the supine sleep position [23], all of which are themselves associated with an increased risk of late stillbirth [24]. Therefore, pregnant women with SDB may have an increased risk of late stillbirth (�28 weeks' gestation) and this risk may be magnified if women settle to sleep supine, however the data is lacking.…”

Section: Introductionmentioning

confidence: 99%

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Associations between symptoms of sleep-disordered breathing and maternal sleep patterns with late stillbirth: Findings from an individual participant data meta-analysis

et al. 2020

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Background and objectives Sleep-disordered breathing (SDB) affects up to one third of women during late pregnancy and is associated with adverse pregnancy outcomes, including hypertension, diabetes, impaired fetal growth, and preterm birth. However, it is unclear if SDB is associated with late stillbirth (�28 weeks' gestation). The aim of this study was to investigate the relationship between self-reported symptoms of SDB and late stillbirth. Methods Data were obtained from five case-control studies (cases 851, controls 2257) from New Zealand (2 studies), Australia, the United Kingdom, and an international study. This was a secondary analysis of an individual participant data meta-analysis that investigated maternal going-to-sleep position and late stillbirth, with a one-stage approach stratified by study and site. Inclusion criteria: singleton, non-anomalous pregnancy, �28 weeks' gestation. Sleep data ('any' snoring, habitual snoring �3 nights per week, the Berlin Questionnaire [BQ], sleep quality, sleep duration, restless sleep, daytime sleepiness, and daytime naps) were collected by self-report for the month before stillbirth. Multivariable analysis adjusted for known major risk factors for stillbirth, including maternal age, body mass index (BMI kg/ m2), ethnicity, parity, education, marital status, pre-existing hypertension and diabetes, smoking, recreational drug use, baby birthweight centile, fetal movement, supine going-to-PLOS ONE

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Association of Supine Going-to-Sleep Position in Late Pregnancy With Reduced Birth Weight

Anderson

Gordon

et al. 2019

JAMA Netw Open

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IMPORTANCE Supine maternal position in the third trimester is associated with reduced uterine blood flow and increased risk of late stillbirth. As reduced uterine blood flow is also associated with fetal growth restriction, this study explored the association between the position in which pregnant women went to sleep and infant birth weight. OBJECTIVE To examine the association between supine position when going to sleep in women after 28 weeks of pregnancy and lower birth weight and birth weight centiles. DESIGN, SETTING, AND PARTICIPANTS Prespecified subgroup analysis using data from controls in an individual participant data meta-analysis of 4 case-control studies investigating sleep and stillbirth in New Zealand, Australia, and the United Kingdom. Participants were women with ongoing pregnancies at 28 weeks' gestation or more at interview. MAIN OUTCOMES AND MEASURES The primary outcome was adjusted mean difference (aMD) in birth weight. Secondary outcomes were birth weight centiles (INTERGROWTH-21st and customized) and adjusted odds ratios (aORs) for birth weight less than 50th and less than 10th centile (small for gestational age) for supine vs nonsupine going-to-sleep position in the last 1 to 4 weeks, adjusted for variables known to be associated with birth size. RESULTS Of 1760 women (mean [SD] age, 30.25 [5.46] years), 57 (3.2%) reported they usually went to sleep supine during the previous 1 to 4 weeks. Adjusted mean (SE) birth weight was 3410 (112) g among women who reported supine position and 3554 (98) g among women who reported nonsupine position (aMD, 144 g; 95% CI, −253 to −36 g; P = .009), representing an approximate 10-percentile reduction in adjusted mean INTERGROWTH-21st (48.5 vs 58.6; aMD, −10.1; 95% CI, −17.1 to −3.1) and customized (40.7 vs 49.7; aMD, −9.0; 95% CI, −16.6 to −1.4) centiles. There was a nonsignificant increase in birth weight at less than the 50th INTERGROWTH-21st centile (aOR, 1.90; 95% CI, 0.83-4.34) and a 2-fold increase in birth weight at less than the 50th customized centile (aOR, 2.12; 95% CI, 1.20-3.76). Going to sleep supine was associated with a 3-fold increase in small for gestational age birth weight by INTERGROWTH-21st standards (aOR, 3.23; 95% CI, 1.37-7.59) and a nonsignificant increase in small for gestational age birth weight customized standards (aOR, 1.63; 95% CI, 0.77-3.44). CONCLUSIONS AND RELEVANCE This study found that going to sleep in a supine position in late pregnancy was independently associated with reduced birth weight and birth weight centile. This novel association is biologically plausible and likely modifiable. Public health campaigns that (continued)

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An Individual Participant Data Meta-analysis of Maternal Going-to-Sleep Position, Interactions with Fetal Vulnerability, and the Risk of Late Stillbirth

Cited by 51 publications

References 35 publications

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004–2015

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004–2015

Associations between symptoms of sleep-disordered breathing and maternal sleep patterns with late stillbirth: Findings from an individual participant data meta-analysis

Association of Supine Going-to-Sleep Position in Late Pregnancy With Reduced Birth Weight

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